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Notice of Privacy Practices

Southern Illinois University School of Medicine and SIU HealthCare 217-545-8000

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The terms of this Notice of Privacy Practices (“Notice”) apply to SIU School of Medicine and SIU HealthCare. The information contained within this Notice will be adhered to by:

Any healthcare professional who treats you at any of our locations.

All departments of SIU School of Medicine and SIU HealthCare.

All employees, associates, staff or volunteers of our organization.

Any business associate or partner with whom we may share information.

Our Requirements

We are required by federal law and applicable state law, regulations, and other authorities to protect the privacy of your personal health information (“PHI”) and to provide you with this Notice. We are required to protect the confidentiality of your PHI and will disclose your PHI to a person other than you or your personal representative only when permitted under federal or state law. This protection extends to any PHI that is oral, written, or electronic, such as health information transmitted by facsimile, modem, or other electronic device. This Notice describes how we may use and disclose your health information. In some circumstances, as described in this Notice, the law permits us to use and disclose your PHI without your express permission. In all other circumstances, we will obtain your written authorization before we use or disclose your PHI. This Notice also describes your rights and the obligations we have regarding the use and disclosure of PHI. Under federal and applicable state law, we are required to follow the terms of the Notice currently in effect. YOU ARE NOT REQUIRED TO AUTHORIZE ADDITIONAL USES AND DISCLOSURES OF YOUR PHI.

Changes To This Notice

We reserve the right to change the terms of this Notice as necessary and to make the new Notice effective for all PHI maintained by us. You may receive a copy of any revised notices at our Website www.siuhealthcare.orq or at any of our clinic sites, or a copy may be obtained by mailing a request to:

1. Treatment: We make uses and disclosures of your PHI as necessary for your treatment. For example, doctors, nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to plan a course of treatment for you that may include procedures, medications, and tests. We may also release your PHI to another health care facility or professional who is not affiliated with our practice but who is or will be providing treatment to you.

2. Payment: We may use and disclose PHI to obtain or provide compensation or reimbursement for providing your healthcare. For example, we may forward information regarding your PHI to your insurance company to arrange for payment for the services provided to you or to prepare a bill to send to you or the person responsible for your payment.

3. Health care operations: We may also use and disclose your PHI as necessary and as permitted by law, for our health care operations. For example, we may use or disclose your PHI to deal with certain administrative aspects of your healthcare. These activities include, but are not limited to, clinical improvement, clinical teaching, professional peer review, business management, accreditation and licensing.

How We May Use And Disclose Your PHI In Other Special Circumstances

We are permitted under federal and applicable state law and are likely to use or disclose your PHI without your permission only when certain circumstances may arise as described below:

Business associates: There are some activities conducted in our organization through other companies termed as “business associates.” Federal law requires us to enter into business associate agreements with these other companies to safeguard your PHI. Examples include physician services, legal services, therapy services, consulting and information technology vendors.

Research: For research we may use and disclose your PHI in limited circumstances. For example, a research organization may wish to compare outcomes of all patients who received a particular medication and will need to review a series of medical records. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidential requirements applied by an Institution Review Board (IRB) or privacy board, which oversees the research.

Individuals involved in your care or payment for your care: With your approval we may, from time to time, disclose your PHI to designated family and friends and others who are involved in your care or payment of your care in order to facilitate that person's involvement in caring for you or paying for your care. If you are unavailable, incapacitated or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited PHI with individuals without your approval.

Disaster relief: We may also disclose limited PHI to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in some aspect of caring for you.

Fundraising: We may contact you to donate to a fundraising effort for or on our behalf. You have the right to "opt-out" of receiving fundraising materials or communications and may do so by sending your name and address together with a statement that you do not wish to receive fundraising materials or communications from us to:

We May Use Or Disclose Your PHI For Other Purposes Only With Your Authorization

We will obtain your valid written authorization before using or disclosing your PHI for purposes other than those described above (or as otherwise permitted or required by law) including before using or disclosing your PHI for marketing purposes or in exchange for remuneration and before using and disclosing your psychotherapy notes. Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. You may revoke such authorization at any time by submitting a written notice to our Privacy Officer at the address listed below. If you revoke your authorization, we will no longer use or disclose PHI about you for the reasons covered by your authorization. Understandably, we are unable to rescind any disclosure we have already made with your authorization.

Obtain a paper copy of this Notice upon request: You have the right to obtain a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. We will provide you with a paper copy promptly. To obtain a copy of this Notice at anytime, go to www.siuhealthcare.org or you may write to our Privacy Officer at SIU HealthCare, P.O. Box 19639, Springfield, IL 62794-9639.

Inspect and obtain a copy of your PHI: You have the right to access and copy your PHI contained in the “designated record set,” which includes medical and billing records. To inspect a copy of your PHI, complete our Access Request Form and submit to our Director of Medical Records. We will respond to your request in writing within 30 days (with a possible 30-day extension). You also have the right to request an electronic copy of your PHI. If your PHI is not readily producible in such an electronic form or format, we will provide your PHI in a readable electronic form and format as agreed to by you and SIU HealthCare. A fee may be charged for the expense of fulfilling your request. We may deny your request to inspect and copy, in certain very limited circumstances, such as if we have reasonably determined that providing access to PHI would endanger your life or safety or cause substantial harm to you or another person. If you are denied access to PHI, you may request that the denial be reviewed in some situations.

Request an amendment of PHI: You have the right to request that PHI we maintain about you be amended or corrected. To request an amendment, submit a written request to our Director of Medical Records. We are not obligated to make all requested amendments. We will give each request careful consideration. We will respond to your request in writing within 60 days (with a possible 30-day extension). In our response, we will either: (i) agree to make the amendment, or (ii) inform you of our denial, explain our reason, and outline appeal procedures, if applicable.

Receive an accounting of disclosures of PHI: You have the right to receive an accounting of your PHI disclosures for purposes other than treatment, payment and healthcare operations. This accounting will exclude disclosures: made directly to you, made with your authorization, made incident to a use or disclosure required by law or regulation, or made to caregivers. To obtain an accounting, submit a written request to our Privacy Officer. We will provide you with one accounting per 12-month period free of charge, but you may be charged for the cost of any subsequent accountings during the same 12-month period.

Request confidential communications: You have the right to request that we communicate with you about your healthcare matters in a certain way or at a certain location. Such request should be submitted in writing. For example, you may ask that we contact you by mail at home or at work. SIU HealthCare will strive to grant requests for confidential communications at alternative locations and/or via alternative means. Please realize that we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

Request restrictions or limitations on the health/medical information we use or disclose about you for treatment, payment, or healthcare operations: You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for your care such as a family member or a representative. Such request should be submitting in writing to our Privacy Officer. For example, you could ask that we not use or disclose information about a surgery that you had. You must identify in this request: (i) what particular information you would like to limit, (ii) whether you want to limit use, disclosure, or both, and (iii) to whom you want the limits to apply. All requests will be carefully considered, but we are not required to agree to those restrictions, except in certain circumstances. We will provide you with a written response to your request within 30 days. If we do agree to restrict use or disclosure of your PHI, we will not apply these restrictions in the event of an emergency. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate an agreed-to restriction by sending such written termination notice to:

Restriction on disclosure of PHI when paying out of pocket: You have the right to request a restriction on the disclosure of your PHI (for payment or healthcare operations) to your health plan when you have paid for the service or item in question completely out of pocket in full by submitting a written request to our Privacy Officer. We are required to agree to this restriction. We will provide you with a written response to your request within 30 days. All requests for PHI must include your full name, date of birth, and address.

Choose someone to act on your behalf: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has the authority and can act for you before we take such action.

Breach notification: You have the right to be notified when a breach of your unsecured PHI has occurred. We will provide you with such notification as soon as information regarding the breach is available.

Organized Health Care Arrangement: Southern Illinois University School of Medicine and SIU HealthCare maintain some of its medical records through the use of a shared electronic health record system. The shared electronic health record system combines protected health information of Southern Illinois University School of Medicine and SIU HealthCare patients with that of other covered entities so that each patient has a single health record with respect to physician office services provided by the participating covered entities in the Springfield, Illinois area. Through the use of the electronic health record system for joint quality assurance and/or utilization review activities, the participating covered entities, including Southern Illinois University School of Medicine, SIU HealthCare, portions of Memorial Health Services, and Springfield Clinic, qualify as an Organized Health Care Arrangement (“OHCA”), as defined by HIPAA. As OHCA participants, all participating covered entities may use and disclose the protected health information contained within the electronic health record for the treatment, payment, and health care operations purposes of each of the OHCA participants.

Complaints: If you believe your privacy rights have been violated, you can file a complaint with our Privacy Officer at:

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independent Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. There will be no retaliation for filing a complaint.

You will be asked to sign a form acknowledging that you received this Notice of Privacy Practices. If you have questions or need further assistance regarding this Notice, you may contact our Privacy Office.